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Chapter 6 Introduction to Pharmacodynamics

The total body water (TBW) accounts for 60% of total body weight in men and 50% of total
body weight in women. While two-thirds of TBW is located in the intracellular compartment,
one-third is located in the extracellular compartment. TBW is reduced in elderly patients because
of reduced muscle mass and increased lipid storage. Because of the higher rate of lipid storage in
such individuals, the availability of hydrophobic drugs in the plasma is low (see the Introduction
to Pharmacokinetics chapter), which results in a delay in these drugs reaching the excretory organs
(e.g., liver, kidneys). The latter process results in an increased duration of action for the drugs.
Elderly individuals are also prone to be affected by physiological changes of aging or patho-
physiological consequences that arise from one or more diseases. For instance, the hepatic
­first-pass effect is reduced in the elderly population, which results in lower hepatic metabolism and
ultimately leads to increased plasma concentration of drugs. Likewise, aging reduces the density
and sensitivity of receptors. For instance, it has been suggested that the sensitivity of muscarinic,
β-adrenergic, α1-adrenergic, and μ-opioid receptors declines as a consequence of aging. A change
in receptors’ sensitivity may cause a change in the affinity between a drug and a receptor, a change
in the binding of a drug to a receptor, or a change in the structure and function of a receptor.

Obesity
Obesity affects both pharmacokinetics and pharmacodynamics by altering the volume of distribu-
tion. The more lipid storage that occurs, the higher the volume of distribution will be for hydro-
phobic drugs. In turn, the higher the volume of distribution, the longer the half-life of drugs (lower
elimination rate; see also the Introduction to Pharmacokinetics chapter). For instance, hydrophobic
drugs such as benzodiazepines have lower elimination rates in obese patients. Moreover, weight
gain often results in insulin resistance. It has been suggested that obese individuals who are not
diabetic may have the same level of insulin resistance as patients who have type 2 diabetes. One
explanation for this phenomenon could be too much circulating fatty acid in the blood. Fatty acids
interfere with glucose uptake into muscle (insulin resistance). This effect could also explain why
pregnant women, who produce large amounts of fatty acids, are prone to develop insulin resistance
(i.e., gestational diabetes).

Receptors
Many important physiological and biological functions are accomplished by chemical
­messengers—that is, hormones or ions that arrive via the bloodstream or neurotransmitters that
are released by nerve cells. These messengers are received by receptors. Many hydrophilic hor-
mones (e.g., peptide hormones such as insulin and glucagon) interact with receptors located in the
plasma membrane and transmit signals to the cytoplasm. The entire process is called transmem-
brane signaling. In contrast, hydrophobic hormones (thyroid, steroid, and retinoid hormones) are
able to cross the cell membrane and interact with their intracellular receptors located inside the
cells. As a result, these hydrophobic ligands do not have any transmembrane receptors, but rather
have intracellular receptors.
Most often the interaction between the messenger and the receptor is achieved noncovalently,
similar to an enzyme–substrate interaction. Hormones are ligands that are the “first messengers,”
whereas Ca2+, cAMP, IP3, diacylglycerol, and cGMP are the “second messengers” that are released
or synthesized when the hormone binds to its receptor. The roles of second messengers are to
stimulate or inhibit a series of biochemical events in the cytoplasm or nucleus.
Many drugs mimic the endogenous ligands and, as a result, are able to bind to p ­ hysiological
receptors. By binding to receptors, these drugs—much like the endogenous ligands—­
initiate a series of events that leads to biochemical changes in a cell and ultimately results in

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 Transmembrane Signaling and Signal Transduction 357

pharmacological responses. Because receptors play important roles in receiving extracellular

signals and turn those signals into intracellular signals, any alteration in receptors’ affinity for their
ligands can have immediate biochemical and physiological impacts.
Not all proteins in the plasma membranes are receptors. While some proteins are receptors,
­others serve as transporters, ion channels, or enzymes. These proteins have essential functions
as well. For instance, due to the hydrophobic nature of the lipid bilayer of the plasma membrane,
anions and cations cannot readily cross plasma membranes. The influx and outflow of ions are
critical regulatory events in both excitable and nonexcitable cells. To maintain the electrochemical
gradients required to maintain or produce a membrane potential, all cells express ion t­ ransporters
for Na+, K+, Ca2+, and Cl−. For instance, the human body expresses more than 200 different ion
channels to regulate precisely the flow of Na+, K+, Ca2+, and Cl− across the cell membranes.
The names of receptors are often designated based on the names of the ligands (or a class
of ligands) that they bind. For instance, while insulin (ligand) binds to an insulin receptor,
­norepinephrine (ligand) binds to adrenergic receptors. A single cell may have different receptors
for different ligands—for example, a hepatocyte has receptors for insulin and glucagon ligands.
In addition, the same receptor for a ligand could be expressed in different cells. For example, insu-
lin receptors are largely expressed on hepatocytes, myocytes, and adipocytes.
Signal transduction refers to the movement of chemical signals (e.g., hormones, neurotransmit-
ters, second messengers) from outside a cell to inside the cell. The movement of signals can follow
a simple path, like the ion channels of the plasma membrane that open and close in response to
a chemical ligand, or can be more complex, like the coupling of ligand–receptor interactions that
leads to a series of protein activation and phosphorylation steps that change enzyme activities and
protein conformations in the cytoplasm of a cell.

Transmembrane Signaling and Signal Transduction

The terms transmembrane signaling and signal transduction have often been used interchange-
ably, even though there is a slight distinction between the two. Transmembrane signaling refers to
sending an extracellular signal through a cell membrane receptor. Signal transduction is a much
broader concept, referring to sending a signal through a cell membrane where the receptor may
not be an embedded cell membrane receptor, but rather an intracellular receptor. For simplicity,
the term “signal transduction” is used throughout this chapter.
Six signal transduction systems are employed by receptors:
1. Gated ion channels
2. Receptor enzymes
3. Serpentine receptors
4. Receptors for hydrophobic ligands
5. Receptors without intrinsic enzyme activity
6. Adhesion receptors
Before these receptors are described and their signaling roles are elucidated, it is necessary to
explain a few important molecules that are involved in the signaling pathways.

Adenylyl Cyclase
Adenylyl cyclase (AC) is a large membrane-bound enzyme that is folded multiple times inside
the cell membrane. It has 12 transmembrane regions, with two bundles of 6 transmembrane

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 358 Chapter 6 Introduction to Pharmacodynamics

components. Adenylyl cyclase catalyzes the synthesis of cyclic adenosine-3',5'-monophosphate

(cAMP) by acting on an ATP molecule. Ten isoforms have been identified to date, including a re­cently
identified free isoform (soluble) in mammalian sperm. Each isoform has a unique tissue expression
and distribution, which may indicate AC catalyzes the formation of cAMP in many d ­ ifferent tissues.
Each AC has two regulatory components—stimulatory G proteins (designated as Gs) and i­nhibitory G
proteins (designated as Gi)—that stimulate and inactivate the catalytic activity of AC, r­ espectively. Due
to AC’s involvement in many signaling pathways, certain hormones stimulate AC (e.g., calcitonin,
glucagon, epinephrine, antidiuretic hormone) while others inhibit AC (e.g., acetylcholine, somatosta-
tin, angiotensin II).

Guanylyl Cyclase
Guanylyl cyclase, similar to AC, catalyzes formation of a cyclic nucleotide, cyclic guanosine mono-
phosphate (cGMP). Guanylyl cyclase exists in two forms: type 1 (transmembrane) and type 2
(a heme-containing soluble enzyme). There are seven isoforms of type 1 and four isoforms of type 2.
Guanylyl cyclases are found in most tissues.
Cardiac atrial tissue (atrial myocytes) express a short peptide (28 amino acids) called atrial
natriuretic peptide (ANP) that has important roles in natriuresis, diuresis, vasodilation, and inhibi-
tion of aldosterone secretion. The ANP activates the membrane-bound guanylyl cyclase, which
results in an increased rate of synthesis of cGMP. In addition, nitric oxide hormone (and even
compounds that contain NO) activates the soluble guanylyl cyclase to synthesize cGMP.

Cyclic Adenosine Monophosphate

The second messenger cAMP is synthesized by the adenylyl cyclase enzyme. Cyclic AMP plays
important roles in many cellular functions, including cell growth and differentiation, regulation of
gene expression, and apoptosis. While cAMP has many targets, perhaps the most relevant one in
this chapter is the cyclic AMP-dependent protein kinase (PKA) that is involved in the adrenergic
receptors’ roles and functions (see the discussion of the role of epinephrine in serpentine receptors
later in this chapter).
cAMP is rapidly degraded by an enzyme called cyclic nucleotide phosphodiesterase. As will be
discussed in conjunction with serpentine receptors in this chapter, cAMP is involved in activation
of glycogen phosphorylase a and glycogenolysis and, as a result, plays a significant role in increas-
ing the blood glucose levels.

Cyclic Guanosine Monophosphate

The guanylyl cyclase enzyme catalyzes formation of cyclic GMP by acting on a GTP molecule.
Similar to the inactivation of cAMP, cGMP phosphodiesterase (PDE) enzyme degrades cGMP.
A few agents, such as sildenafil (Viagra) and tadalafil (Cialis), inhibit cGMP phosphodiesterase
(PDE) to increase the level of cGMP. The cyclic GMP plays a major role in promoting smooth
muscle relaxation by inhibiting calcium influx, activating potassium channels, and stimulating
cGMP-dependent kinase (PKG)—mechanisms that will be discussed further later in this chapter.

Calcium
Calcium is another important second messenger that plays important roles in the signal transduc-
tion. The concentration of Ca2+ in the cytoplasm is very low (10−6 M), while the concentration
outside the cell and inside the endoplasmic reticulum (ER) is 10−3 M. Calcium regulates a series of
responses that include gene expression, contraction, secretion, and metabolism. It can enter a cell
through ion channels (Ca2+ channels) that are located in the plasma membrane or it can be released

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 Transmembrane Signaling and Signal Transduction 359

from intercellular storage by hormones or growth factors. For instance, when the calcium channels
in the ER open, Ca2+ is released into the cytoplasm. Intracellular Ca2+ levels cause skeletal muscle
cells to contract and stimulate some endocrine cells to secrete hormones.
Because calcium plays an important role in many cellular functions, disruption of calcium influx
or efflux can have severe physiological consequences. For instance, damage to the ligand-gated
Ca2+ channel or voltage-gated Ca2+ channel (discussed later) causes Ca2+ to move down its concen-
tration gradient into the cytoplasm of cells. The resulting increase in intracellular Ca2+ inhibits the
ATPase enzyme during oxidative phosphorylation (which results in less synthesis of ATP), alters
the function of microfilaments, enhances the activation of hydrolytic enzymes, and increases the
generation of reactive species such as reactive nitrogen species (RNS) and reactive oxygen species
(ROS), which ultimately damage many other cells.
Some of the serpentine receptors (see the discussion of serpentine receptors later in this
c­ hapter), by binding to their ligands, activate their G protein, Gq. For example, when the oxytocin
or vasopressin hormones bind to their receptors, the α subunit of Gq in turn binds to and activates
a plasma membrane enzyme called phospholipase C. Phospholipase C catalyzes the production
of two other second messengers, inositol 1,4,5-triphosphate (IP3) and diacylglycerol, from the
phosphatidylinositol 4,5-bisphosphate found in the plasma membrane. IP3 has its own receptor.
This IP3 receptor is a large protein and is found in high concentrations in the membrane of the ER.
The role of IP3 molecules is to diffuse through the cytoplasm to the ER and bind to the specific IP3
receptor. The binding of IP3 to its receptor stimulates Ca2+ channels to open and releases Ca2+ into
the cytoplasm (Figure 6.4). The released Ca2+, together with the diacylglycerol, activates another
protein kinase, PKC, which in turn phosphorylates a variety of proteins to change their activities
and, consequently, to mediate a wide range of signaling events.
Calcium regulates a number of enzymes, often through a Ca2+ binding protein called ­calmodulin.
This small protein is found in all eukaryotic cells. Due to its unique structure, calmodulin is able

Ligand

Phospholipase C Diacylglycerol

Receptor

Gq-GDP Gq-GTP
Protein kinase C
IP3 receptor
IP3
ER Ca2+ Ca2+
Phosphorylation of
many cellular proteins
Ca2+ receptor

Figure 6.4  Binding of a ligand to its receptor activates phospholipase C, which in turn releases diacylglycerol and
IP3 from the phospholipids of the cell membrane. The overall results are to increase intracellular Ca2+ and activate
protein kinase C.
Adapted from: Nelson DL, Cox MM, and Lehninger AL. Principles of biochemistry, 5th ed. New York: W. H. Freeman and
Company; 2008: Chapter 12.

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 360 Chapter 6 Introduction to Pharmacodynamics

ATP cAMP activation of PKA phosphorylation of proteins

Adenylate
Cell membrane
cyclase

Physiological effects

Figure 6.5  The cAMP-dependent protein kinase A (PKA) is activated by cAMP that is synthesized by the adenylate
cyclase enzyme.

to bind four calcium ions and, therefore, serves as an intracellular receptor for regulatory calcium
signals. An increase in cytosolic Ca2+ concentration allows Ca2+ to bind to the four binding sites on
calmodulin. As a consequence of the Ca2+ binding, calmodulin undergoes a conformational change
that allows it to interact with other cytoplasmic proteins to influence a series of cellular responses.
The activation of calmodulin by Ca2+ is similar to the activation of PKA by cAMP, except here the
Ca2+–calmodulin complex has no enzymatic activity on its own, but rather activates other proteins
and enzymes.

Protein Kinases
Protein kinases are a class of enzymes that transfer a phosphate group from an ATP molecule to a
protein—a reversible process called protein phosphorylation. Protein phosphorylation is primarily
directed at serine, threonine, and tyrosine amino acid residues in proteins (all of these amino acid
residues have an OH group; see also the Introduction to Cell Biology chapter). Nearly one-third of
our proteins inside of cells are phosphorylated by protein kinases. More than 100 protein kinases
have been identified in humans; indeed, the human genome has about 500 protein kinase genes.
Protein phosphorylation plays an important role in the regulation of protein kinases. For instance,
protein kinase A (PKA) is not activated until a cAMP molecule participates in PKA phosphoryla-
tion (Figure 6.5). While the overall function of kinases is to phosphorylate other proteins, there
are considerable differences among them in regard to their size, subunit composition, auto-­
phosphorylation, kinetic parameters (e.g., Km, kcat), and substrate specificity.
One of the major roles of protein kinases is the regulation of the cell cycle. The passage of a cell
from one phase to another through the cell cycle is controlled by proteins called cyclins. Cyclins
are regulatory subunits of a series of protein kinases called cyclin-dependent protein kinases
(CDKs). These proteins have no kinase activities unless they are tightly bound to the cyclins. For
instance, while CDK1 facilitates the transition from the G2 phase to the M phase during the cell
cycle, CDK2 initiates DNA synthesis in the early S phase (Figure 6.6). To date, 9 CDKs (referred to
as CDK1 through CDK9) and 11 cyclins have been identified in humans.

Gated Ion Channels

Many drugs act on their receptors to stimulate or inhibit the influx of ions through cell membrane
channels. For instance, a few drugs that cause calcium influx can affect the release of neurotrans-
mitters and gene expression. Similarly, endogenous ligands can bind to their receptors and open
ion channels. For instance, the endogenous ligand known as acetylcholine binds to acetylcholine
receptor and increases the Na+ influx from the extracellular fluid into the cells. Based on gating

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 Transmembrane Signaling and Signal Transduction 361

CDK1-cyclin A
M phase
CDK1-cyclin B
(1–2 hours)

G2 phase
(3–4 hours)

CDK4-cyclin D
G1 phase
(6–12 hours) CDK6-cyclin D
S phase
(6–8 hours)

CDK2-cyclin A

CDK2-cyclin E

Figure 6.6  The eukaryotic cell cycle and the points where cyclin-dependent protein kinases (CDKs) are activated
by different cyclins.
Adapted from: Murray RK, Jacob M, Varghese J. Cancer: an overview. In: Murray RK, Kennelly PJ, Rodwell VW, et al., eds.
Harper’s illustrated biochemistry, 29th ed. New York: McGraw-Hill; 2011. Available at: http://www.accesspharmacy.com
/content.aspx?aID=55887057.

Na+

Closed gate Open gate

Depolarization
Ion channel

Ion channel

Cell
membrane

Hyperpolarization

Figure 6.7  Voltage-gated ion channels open and close as a result of changes in the cell membrane potential.

mechanisms, the gated ion channels are classified as either voltage-gated ion channels or ligand-
gated ion channels. The movement of ions across these two gates results in an influx of cations into
the cell to cause depolarization or an influx of anions to cause hyperpolarization.

Voltage-Gated Ion Channels

Voltage-gated ion channels do not bind to their ligands directly, but rather (and as their name
­indicates) respond and are controlled by a change in the membrane potential. In other words, the
opening probability of these channels depends on the membrane voltage (Figure 6.7). Voltage-gated
ion channels provide a major pathway for K+, Cl−, Na+, and Ca2+ ions in many types of cells. For
example, K+, Na+, and Ca2+ gates open when the membrane potential becomes more positive inside

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 362 Chapter 6 Introduction to Pharmacodynamics

(i.e., when the membrane potential is depolarized). For instance, the voltage-gated Na+ channels
­
are
closed when the voltage of the membrane is –60 mV (i.e., when the membrane is at rest), but are
open when the membrane is depolarized (i.e., when the inside of the cell is positive). The depolar-
ization effect arrives when acetylcholine binds to its receptor. These ion channels are very selective
and the rate of influx is high. For instance, the Na+ channel is 100 times more selective for Na+ than
for Ca2+ or K+ ions, and the rate of ion influx is more than 10 million Na+ ions per second.
Another example of how the voltage-gated ion channels work, and indeed communicate with
other channels, is when the opening of Na+ channels in the previous example causes depolarization of
nerve cells, which in turn opens the voltage-gated Ca2+ channels and results in an influx of Ca2+ ions.
An increased entry of intracellular Ca2+ into the presynaptic neuron results in the release of acetyl-
choline neurotransmitter from the secretory vesicles containing acetylcholine into the synaptic cleft.
The acetylcholine binds to its receptor on the next neuron and causes opening of voltage-gated Na+
channels. The entire cycle is then repeated to send the action potential from one neuron to another.
Use of the calcium-channel blocker agent, verapamil (Calan), demonstrates how blocking these
channels causes a physiological change. Verapamil inhibits voltage-gated calcium channels in the
vascular smooth muscle and myocardium so as to reduce blood pressure and produce antiarrhyth-
mic effects, respectively. A series of anticonvulsant agents act through the voltage-gated sodium
channels. For instance, phenytoin (Dilantin) and carbamazepine (TEGretol) decrease seizure
­activity by decreasing the influx of Na+ ions across cell membranes.

Ligand-Gated Ion Channels

To explain this class of gated ion channels, one can return to the neurotransmitter acetylcholine
as an example. The acetylcholine receptor and its ligand acetylcholine, and their roles in signal
transduction, have been studied extensively. The nicotinic acetylcholine receptor is found in the
postsynaptic membrane of neurons at certain synapses and in myocytes at neuromuscular junc-
tions. Synaptic vesicles in synaptic knobs contain approximately 10,000 acetylcholine molecules
per vesicle. The released acetylcholine binds to its receptor on the postsynaptic neuron, which in
turn results in the influx of Na+ into the cell.
The acetylcholine receptor serves as an ion channel and opens in response to the neurotransmit-
ter acetylcholine (a ligand—compare it with the voltage-gated ion channel, in which the channel
opens as a result of a change in the membrane potential). The receptor (ion channel) is formed
from five subunits (two α subunits and one subunit each of β, γ, and δ), where the N termini of
the two α subunits bind the neurotransmitter
acetylcholine. The effects of acetylcholine on Acetylcholine
the postsynaptic ion channel are mainly due to
protein conformational changes. By binding to Na+

its receptor, acetylcholine changes the receptor

conformation from a closed to an opened form. α subunit α subunit
As a result, Na+, Ca2+, or K+ moves in (other ions
cannot move in). The ligand binding is positively
Cell
cooperative, such that binding to the first α membrane
subunit increases the binding affinity of other α
subunits to acetylcholine (Figure 6.8).
While the role of the acetylcholine receptor
channel is to facilitate influx of ions and is a typi- Acetylcholine receptor
cal example of a ligand-gated ion channel, similar Figure 6.8  A ligand-gated ion channel reacting to its
ion channels have been studied for the serotonin ligand, acetylcholine.

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 Transmembrane Signaling and Signal Transduction 363

neurotransmitter and amino acid ligands such as

Insulin glutamate and glycine. For instance, binding of
α subunit α subunit the serotonin or glutamate ligands to their recep-
β subunit β subunit tor channels facilitates ion entry of K+, Na+, and
Ca2+; in contrast, binding of the glycine ligand to
its receptor channel facilitates ion entry of Cl−.
Another example is binding of the major inhibi-
Cell tory neurotransmitter gamma-aminobutyric acid
membrane
(GABA) to its receptor channel, which facilitates
entry of Cl− ion, causing hyperpolarization of the
Intracellular neuron. Because GABA has an inhibitory effect
domains on the action potential (through entry of Cl− and
hyperpolarization of neurons), benzodiazepines
P P
have been suggested to increase the entry of
Insulin receptor Cl− ions through the GABA receptor as well.
However, benzodiazepines do not compete with
Figure 6.9  A receptor enzyme. The intercellular
domains of the insulin receptor undergo auto- GABA for the GABA’s binding site, but rather
phosphorylation upon binding of insulin to its bind to their own binding site on the GABA
receptor. receptor.

Receptor Enzymes
Receptor enzymes have two domains: a single membrane-spanning domain that faces the
­extracellular environment for receiving a signal and a catalytic domain that faces the cytosol of a
cell. The catalytic domain (or the intracellular domain) could be a protein tyrosine kinase, a serine
kinase, or a guanylyl cyclase. The binding of the ligand activates the enzymatic domain, which in
turn affects cellular metabolism by phosphorylation of different target proteins (Figure 6.9).
In the receptor enzyme signal transduction system, important receptors include epidermal
growth factor (EGF), insulin receptor, and many other trophic hormones. Insulin receptor is a
glycoprotein that has two α and two β subunits, all of which are stabilized by disulfide bonds.
The intracellular domain of the β chains are the site of tyrosine kinase activity. The tyrosine kinase
activity of the β subunit is triggered by auto-phosphorylation of Tyr residues in the C-terminal
domain of the β subunit. This tyrosine kinase then transfers a phosphoryl group from ATP
molecules to the hydroxyl group of Tyr residues of other target proteins such as insulin receptor
substrate (IRS).
Because many of the tyrosine kinases are involved in signaling pathways in neoplastic d ­ iseases,
some of the receptor enzymes are good targets for therapeutic agents that seek to inhibit the
­signaling pathways. For example, the monoclonal antibody trastuzumab (Herceptin) binds
to the extracellular domain of the human epidermal growth factor receptor 2 (HER-2) and
thereby ­produces cellular cytotoxicity by inhibiting the S phase of the cell cycle (recall from the
Introduction to Cell Biology chapter that the S phase is where DNA, RNA, and protein synthesis
occur). In doing so, it suppresses the expression of HER-2 receptors on cancerous cells. The HER-2
receptor is overexpressed in approximately 30% of patients who have developed breast cancer. In
addition, this receptor is found, albeit to different degrees, in other malignancies such as ovarian,
lung, and prostate cancers. Due to pharmacogenomics and genetic variations among patients, it is
­imperative to check whether the patient is overexpressing the gene for HER-2 to ensure that he or
she will be able to benefit from a trastuzumab treatment, a process that is discussed more in detail
in the Introduction to Pharmacogenomics chapter.

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 364 Chapter 6 Introduction to Pharmacodynamics

Epinephrine Ligand
N terminal Serpentine
receptor

Cell
membrane

C terminal
G protein
(facing cytosol)

Figure 6.10  A serpentine receptor that has been folded back and forth seven times inside of the cell membrane.

Serpentine Receptors
Serpentine receptors bind to extracellular ligands and enhance intracellular concentrations of
second messengers such as cAMP, Ca2+, and phosphoinositides. The second messengers that are
small molecules or ions bind to a variety of proteins and thereby change the shapes and functions
of those proteins. Upon binding of the ligand to a serpentine receptor, a G protein that is located
on the cytoplasmic face of the plasma membrane becomes activated. Consequently, these recep-
tors are called G-protein receptors. A unique characteristic of a serpentine receptor (as indicated
by its name) is that the receptor is folded and embedded back and forth seven times across the cell
membrane (Figure 6.10).
Serpentine receptors are targets of many drugs, including antihistamines, neuroleptics,
antidepressants, and antihypertensive agents. An example of a serpentine receptor is the
β-adrenergic receptor. In 2012, two scientists, Brian Kobilka and Robert Lefkowitz, won the
Nobel Prize in chemistry for their work elucidating the signaling mechanism for
serpentine receptors.
The following discussion briefly describes the role of a serpentine receptor. Epinephrine is an
adrenergic ligand that binds to its specific receptor (β-adrenergic receptor) on the cell surface. This
binding promotes a conformational change in the cytosolic domain of the receptor, which in turn
binds to a Gs protein. The α subunit of the Gs protein has the binding site for either GDP or GTP.
The ligand-bound receptor causes GTP to replace GDP, such that the Gs protein becomes acti-
vated. The Gs protein then activates adenylate cyclase, which catalyzes the synthesis of cAMP. The
cAMP-dependent protein kinase, PKA, becomes activated by cAMP. PKA activates phosphorylase
b kinase, which in turn converts glycogen phosphorylase b to glycogen phosphorylase a, which
finally leads to glycogenolysis (Figure 6.11). PKA is able to phosphorylate many physiological tar-
gets, including metabolic enzymes, transport proteins, regulatory proteins, other protein kinases,
ion channels, and transcription factors.
Different serpentine receptors may utilize the G proteins differently. Indeed, it is known that
G proteins facilitate the sending of signals for more than 500 receptors. Whereas Gs activates

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 Transmembrane Signaling and Signal Transduction 365

Release of glucose
into circulation

Inactive
Inactive
Epinephrine glycogen
cAMP is PKA is phosphorylase Glycogen is
binds to its phosphorylase
produced activated b kinase is broken
receptor is converted to
activated
active form

Figure 6.11  The cascade of reactions that occur when epinephrine binds to a serpentine receptor (β-adrenergic
receptor).

adenylate cyclase when epinephrine binds to its β-adrenergic receptors, Gq activates phospholi-
pase C to generate diacylglycerol and IP3 when oxytocin or vasopressin hormones bind to their
serpentine receptors. In addition, when epinephrine binds to an α2-adrenergic receptor, the
enzymatic activity of AC is inhibited because the
α2-adrenergic receptor is not coupled to Gs, but
rather to Gi, which is an inhibitory G protein.
Light Cornea
The detection of light (vision), odors (olfac-
tion), and tastes (gustation) in vertebrates also
employs serpentine receptors, which act through
the G proteins to change the sensory neurons’
Lens electrical potential. The retina is made of three
layers of cells: (1) rods and cones; (2) intercon-
necting neurons (bipolar cells); and (3) ganglion
cells (Figure 6.12).
Cone cells function in bright light and are
responsible for color vision. A human retina
contains approximately 6 million cone cells.
Ganglion neurons
Because cones require a reasonable amount of
Retina Interconnecting neurons light to be stimulated, they function only during
the day. This is why we are able to see colors
Rod and cone cells
only during the daytime—in other words, when
the light intensity is high enough to stimulate
Figure 6.12  The anatomy of the eye where light the cone receptors.
reaches the retina to induce a signal transduction.
The light must first pass through both the
Adapted from: Nelson DL, Cox MM, and Lehninger AL.
Principles of biochemistry, 5th ed. New York:
ganglion cells and the bipolar cells before
W. H. Freeman and Company; 2008; Chapter 12. it can reach and affect the photoreceptors

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 366 Chapter 6 Introduction to Pharmacodynamics

(rod and cone cells). Rod and cone cells in the retina contain rhodopsin and photopsin,
­respectively. Rhodopsin and photopsin, which are structurally very similar, contain a light-
absorbing pigment. Rhodopsin has a typical serpentine architecture. It consists of a protein
called opsin linked to a prosthetic group called 11-cis retinal, a vitamin A derivative. When
a photon of energy is absorbed by the retinal c­ omponent of rhodopsin, the conformation of
the prosthetic group is altered, which in turn changes the conformation of rhodopsin—the
first stage in visual transduction. The conformational changes in rhodopsin (upon receiv-
ing photons of energy) result in a decrease in the concentration of cyclic GMP. A decrease in
cGMP in the outer segment of the rod cell causes Na+- and Ca2+-gated ion channels to close.
This leads to hyperpolarization of the cell membrane, which triggers an electrical signal to
be sent to the brain. The drugs sildenafil and tadalafil, both of which inhibit cGMP phospho-
diesterase (PDE), increase the amount of cGMP and cause dose-related impairment of color
discrimination.

Interruption of Signaling Pathways

Toxins produced by Bordetella pertussis (which causes whooping cough) and Vibrio ­cholerae
(which causes cholera, a life-threatening dehydration caused by watery diarrhea) are able
to increase the synthesis of cAMP and thereby interrupt many hosts’ cellular functions.
The cholera toxin, for example, catalyzes the addition of the ADP-ribose moiety of nicotin-
amide adenine dinucleotide (NAD) to the α subunit of the Gs protein and inhibits the Gs
protein’s GTPase activity, thereby making the Gs protein remain attached to GTP (which is the
active form of Gs). The activated Gs protein stimulates adenylate cyclase to produce cAMP
continuously, which in turn stimulates water, bicarbonate, and Cl− secretion into the
intestinal lumen.
Similarly, B. pertussis catalyzes the addition of the ADP-ribose moiety of NAD to the Gi pro-
tein and inhibits displacement of GDP by GTP. This action finally blocks the effect of Gi to inhibit
adenylate cyclase.
Both Gs and Gi are active when they are in their GTP-bound forms and inactive when they are
in their GDP-bound forms. Both toxins interfere with signal transduction and affect a series of the
metabolic events that are dependent on the signaling pathways.
Graves’s disease is another example in which the signaling pathway is interrupted. Graves’s
disease causes production of antibodies that serve as agonists to the thyroid-stimulating hormone
(TSH) protein, a serpentine receptor. Binding of the antibodies activates the AC enzyme, lead-
ing to increased synthesis of cAMP. The cAMP stimulates the expression of the thyroglobulin and
thyroid peroxidase genes. Ultimately, the overall effect is to cause the thyroid pathophysiology
(excessive secretion of the thyroid hormone, T4) evident in Graves’s disease. In addition, in many
patients with McCune-Albright syndrome (a rare genetic syndrome characterized by bone disor-
ders, skin hyperpigmentation, and endocrine dysfunction), the G-protein signaling in the TSH
receptor is interrupted, such that these patients produce excessive thyroid hormones similar to the
case in Graves’s disease.
Xanthine derivatives such as caffeine and theophylline are known to inhibit cyclic nucleotide
phosphodiesterase and increase the amount of cAMP present. The elevated cAMP level stimulates
activation of glycogen phosphorylase a and glycogenolysis; and increased blood glucose level in
the body soon follows (see also Figure 6.11).

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 Transmembrane Signaling and Signal Transduction 367

Learning Bridge 6.1

Joe is a 28-year-old biochemist who works for the United Nations in its International Affairs
division. He just returned from a trip abroad. Joe comes to your pharmacy and complains
about dehydration that has been caused by watery diarrhea. One of the attending physicians
at a local clinic, which Joe visited yesterday, mentioned that he has contracted some bacterial
infections overseas. To Joe’s surprise, the attending physician did not prescribe any antibiotic.
However, the physician asked him to contact a pharmacist and buy an oral rehydration solu-
tion (ORS). You also notice that Joe has sunken eyes and appears weak.
Joe comes to the counter and asks you a few questions:

A. Which kind of infection do I have that does not require an antibiotic?

B. Why have I been asked to buy an ORS?
C. I have a master of science in biochemistry. Can you please tell me, on the cellular level,
why I have watery diarrhea?

Receptors for Hydrophobic Ligands

A few ligands are hydrophobic and, as a result, do not have any plasma membrane receptors;
instead, their targeted proteins are intracellular receptors. In this class, one can find steroids
(corticosteroids, mineralocorticoids, sex steroids, and vitamin D) and thyroid hormones.
These receptors are involved in the expression of genes. Because these ligands are hydropho-
bic, they are strictly dependent on other proteins to assist them in traveling from the site of
their synthesis to the site of their action through the blood circulation. For instance, transcor-
tin, androgen-binding proteins, and sex-hormone-binding proteins assist steroid hormones in
the blood to travel and reach their target cells, and transthyretin assists thyroid hormones in
doing the same.
Once the steroid hormones reach their target cells, they dissociate from their transport proteins,
spontaneously pass through the cell membrane and enter the cytoplasm, bind to their receptor,
and then migrate to the nucleus. In the nucleus, their function is to induce (or, to a lesser extent,
repress) transcription of specific genes. The receptors that bind steroid hormones have a high-
affinity ligand-binding property. These receptors belong to a large family of structurally similar
DNA-binding proteins. Depending on the nature of the steroid hormones, the receptor-binding
complex may occur in the cytoplasm (e.g., for glucocorticoids) or in the nucleus (e.g., for estrogen
and androgen).
Binding of steroids to their receptors changes the conformation of these receptors in which the
hormone–receptor complex can bind to specific DNA sequences called hormone response e­ lement
(HRE). The binding to HRE can either activate or repress the transcription of adjacent genes
(Figure 6.13).
Steroid receptors share some structural similarities. All of the known steroid receptors contain a
small DNA-binding domain that contains zinc, which is an essential element for the DNA binding.
The zinc stabilizes the structure of the domain; without it, the domain would unfold.

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 368 Chapter 6 Introduction to Pharmacodynamics

Steroid hormone
Plasma membrane

Nucleus
Hormone–receptor
complex Gene

HRE

Changing cellular
functions Expressed protein

Figure 6.13  Due to steroid hormones’ hydrophobic structures, they can readily span the plasma membrane so as
to enter the cytoplasm or nucleus.

A hormone–receptor complex can bind to several HREs and, as a result, many gene expressions
can be changed by the same hormone. Each type of HRE can influence the transcription of a large
number of genes (50–100 genes). For this reason, binding of a steroid hormone–receptor complex
to its HRE has a large amplified effect on cellular function.
Steroid hormones—in contrast to peptide hormones, which rapidly act on membrane recep-
tors (recall the roles of glucagon and insulin)—are relatively slow acting. The reason for their
slow action is that it takes longer (30 minutes to several hours) to activate the expression of a
gene for the synthesis of an enzyme or a protein than to act directly on preexisting enzymes.
The slow action partially explains why steroids (e.g., budesonide, fluticasone) are not appropri-
ate for rapidly relieving breathing difficulty in acute bronchial asthma. However, the action of
steroid hormones lasts for a longer duration (hours to days) than that of peptide hormones. The
reason for the longer effect is that the turnover of most enzymes and proteins expressed by these
ligands is slow.

Learning Bridge 6.2

Amy Johnson is a 48-year-old fashion designer who works for a well-known clothing company
on the West Coast. Amy was diagnosed with type 2 diabetes six months ago. She comes to
your pharmacy for a refill of her prescription, metformin (Glucophage), 500 mg twice daily.
Upon a routine review of her medical records, you notice that despite filling her prescription
for ­metformin since her diagnosis, Amy’s blood glucose has remained high (120 mg/dL).
You decide to talk to her to learn more about her medical adherence. Amy admits that she
occasionally forgets to take the second metformin tablet, although that occurs only rarely.
She also mentions that she drinks three cups of tea and three cups of coffee every day.
What is your reaction to Amy’s responses? Use your knowledge about signal transduction
to justify your answer.

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